Background

The Whipple procedure is alternatively referred to as pancreaticoduodenectomy which is a sophisticated surgical intervention employed for treatment of diverse conditions impacting pancreas, duodenum, and adjacent structures. It is named after American surgeon Allen Whipple who was first described this procedure in 1935. The Whipple technique can be used to treat benign tumors, chronic pancreatitis, and some forms of cysts although it is mostly used to treat pancreatic cancer.  

Pancreaticoduodenectomy  

Indications

Pancreatic Cancer  

Benign Tumors  

Chronic Pancreatitis  

Ampullary Tumors  

Trauma  

Contraindications

The Whipple procedure may not be effective in cases of advanced cancer, distant metastases, and patients unable to withstand surgery due to factors like weakened immune systems, weight loss, or other medical complications.  

Outcomes

Equipment 

Scalpel are used for making incisions.  

Scissors used her for cutting tissues.  

Forceps for grasping and holding tissues.  

Needle holders used for suturing.  

Retractors to hold back tissues and provide better visibility.  

Clamps to control bleeding by compressing blood vessels.  

Suction devices applied to remove blood and fluids from the surgical site.   

Patient preparation

This process is carried out while patient is under general anesthesia. The preoperative assessment for anesthesia encompasses following steps.  

Cardiac risk factors  

Functional status  

Nutritional status  

Patient position

Supine Position:   

The patient is usually positioned on operating table lying flat on their back to access the abdomen from front.  

Technique 

Approach considerations   

The process of conducting PPPD can be visualized as a step-by-step progression in a clockwise direction.   

Initially attention is given to address the ascending colon and hepatic flexure to expose superior mesenteric vein.   

Then focus the shifts to porta hepatis for dissection of portal lymph node and cholecystectomy followed by transection of either stomach or proximal duodenum.   

Next, jejunum is divided the retroperitoneal dissection is completed allowing for the removal of the specimen in one piece.   

Alternatively, reconstructions can be performed in a counterclockwise direction.  

Laparotomy and Abdominal Exploration 

Step 1:   

A laparotomy is performed by either bilateral subcostal incisions or broad midline incision.  

Step 2:  

The liver is palpated then peritoneum is examined and next para-aortic lymph nodes, mesentery root, and lymph nodes are assessed.  

Step 3:  

In cases, where preoperative imaging fails to provide definitive results the intraoperative hepatic ultrasonography becomes essential. 
Step 4:  

Additionally, abdominal examination might be conducted as a staging laparoscopy preceding laparotomy for patients with advanced ailments like markedly enhanced levels of carbohydrate antigen or large tumors.  

Step 5:  

Close monitoring is being implemented for individuals considered to be at risk of developing radiographically silent metastatic conditions.  

Exposure of the extended kocherization and superior mesenteric artery 

Step 1:   

The self-retaining retractor facilitates thorough visualization of surgical area. Identification and preservation of falciform ligament are conducted for potential future utilization.  

Step 2:  

Two techniques employed to mobilize ascending colon where hepatic flexure is right medial visceral rotation and Cattell-Brasch maneuver. These maneuvers aim to reveal third and fourth segment of the duodenum.  

Step 3:  

This procedure begins with accessing lesser sac and initiating entry which is followed by locating and securely tying off middle colic vein. This step facilitates the visualization and access to superior mesenteric vein.  

Step 4:  

Upon diagnosis, ligation of gastroepiploic vein may be performed. This anatomical structure is frequently observed connecting with gastrocolic trunk by middle colic vein.  

Step 5:  

Next, a modified Kocher maneuver is executed by commencing from juncture of right gonadal vein and right ureter which extends towards the intersection of left renal vein and aorta.  

Step 6:  

It is very essential to activate lymphatic tissues in between. This involves recognizing the superior mesenteric artery which is pivotal in this regard.  

Portal dissection & Cholecystectomy 

Step 1:  

It is proven that left stomach artery is preserved and celiac axis is located there.   

Step 2:  

The GDA’s point of common hepatic artery is excised and artery is dissected both distally and proximally from point where gastroduodenal artery branches off.  

Step 3:  

The task is performed and GDA is thoroughly analyzed.  

Step 4:  

In a cholecystectomy procedure the specimen is cut at the point where common hepatic duct intersects with cystic duct located slightly above it.  

Step 5:  

Intraoperative pathological evaluation if necessary enlargement is performed on the CHD edge.  

Step 6:  

Surgeons needs to examine whether there is a replaced or right hepatic artery which can occur because of anatomical alterations in common hepatic artery following identification of these vessel origins.  

Step 7:  

The frontal aspect of portal vein becomes visible during medial retraction employing common hepatic artery.  

Step 8:  

The surgeon carefully follows path of the portal vein until it joins with superior mesenteric vein behind pancreas’s neck.  

Step 9:  

Special attention is given to prevent accidental traction injuries to duodenum adjacent to posterior pancreas.  

Duodenal transection if pancreaticoduodenectomy acceptable 

Step 1:  

Tumors located in pancreatic head and those that metastasize to the first or second part of duodenum align with established oncological protocols.  

Step 2:  

At this point presence of clinically positive regional lymph nodes makes it impossible to preserve the pylorus. When a PPPD is performed successfully duodenum divides around 2 to 3 cm beyond pylorus.   

Step 3:  

Duodenal cuff is adequately elongated to endure any potential modifications required during subsequent formation of duodenojejunal anastomosis.  

Step 4:  

The gastroepiploic artery and vein undergo separation followed by identification and protection of right gastric artery.  

Step 5:  

The separation of jejunum occurs a minimum of 10 cm from ligament of Treitz while duodenum divides 2 to 3 cm beyond pylorus.  

Step 6:  

Underneath mesenteric arteries the duodenum and jejunum are turned downward and mesenteries of both severed small-bowel stumps are similarly divided.  

Division of pancreas 

Step 1:  

The pancreas is incised at level of portal vein which is exposing the junction of superior mesenteric vein and PV beneath.  

Step 2:  

If  tumor is connected to this junction as well as the SMV and PV individually then there might be a need to adjust the pancreatic division plane farther down to aid in reconstruction of the vein.  

Step 3:  

Carefully separate the tumor from venous structures that are specifically identified.   

Step 4:  

If jejunal branch of the superior mesenteric vein is harmed in this area addressing the venous injury becomes difficult and trying to fix it could potentially harm superior mesenteric artery.  

Removal & orientation of specimen 

Step 1:  

The specimen is collected intact and prepared for pathological evaluation. Retroperitoneal margin is delineated for assessment by pathological frozen section procedure.  

Step 2:  

An excessively positive retroperitoneal boundary indicates technical shortfall in attaining desired R0 resection objective.  

Step 3:  

In cases of pancreaticoduodenal resections for pancreatic head cancer approximately 10 to 20% may exhibit microscopic positive margins in retroperitoneum.  

Pancreatic reconstruction 

Step 1:  

The first step is to mobilize pancreatic remnant over a short distance. Afterward, the sectioned jejunum is inserted through an opening in transverse mesocolon which is situated close to middle colic vessels.  

Step 2:  

The establishment of the pancreaticojejunal anastomosis recognizes development of pancreatic fistulas is dependent on features of the pancreatic tissue in addition to technical coherence of anastomosis.  

Step 3:  

A surgical procedure like duct-to-mucosa reconstruction or two-layer end-to-side pancreaticojejunostomy is carried out. This involves ensuring complete closure of full-thickness pancreatic duct to jejunal wall.  

Step 4:  

The pancreatic tissue and lining of the jejunum are divided by seromuscular sutures that are spaced between them. These sutures are initially positioned along outer row towards the back. Subsequently, a longitudinal cut is made in jejunum in front of where these sutures are located.  

Step 5:  

The interrupted full-thickness sutures within the inner circumferential layer serve to unite severed pancreatic duct with jejunal wall facilitating their proximity. Following the secure placement of posterior sutures within the anastomosis a pancreatic stent is introduced.  

Step 6:  

Following this, remaining sutures are secured externally. The outer layer anteriorly is established by placing a series of interrupted seromuscular sutures.  

Step 7:  

Alternatively, the distal pancreatic stump could be invaginated into jejunum from side to side or end to end.  

Step 8:  

The exterior sutures are strategically placed to penetrate the pancreatic remnant whereas interior layer is arranged in circumferential layers.  

Step 9:  

This method proves beneficial in cases where pancreatic duct remains undilated and parenchyma lacks firmness required to withstand jejunal seromuscular sutures.  

Biliary reconstruction 

Step 1:  

During hepaticojejunostomy surgery a connection is formed between the remaining common hepatic duct and a location on jejunum beyond pancreaticojejunal anastomosis utilizing a single-layer end-to-side anastomosis technique.  

Step 2:  

Prior to suturing it is essential to ensure that both jejunum and bile duct are correctly aligned and devoid of tension.  

Closing maneuvers 

Step 1:  

The Witzel procedure establishes a feeding jejunostomy positioned above duodenojejunal anastomosis by ensuring ongoing enteral feeding accessibility throughout recovery process.  

Step 2:  

To prevent the development of a pseudoaneurysm in GDA due to a pancreatic leak the surgeons utilize identification and application of falciform ligament to protect stump of the GDA.  

Step 3:  

Furthermore, another method entails utilizing a vascularized omental flap to cover the stump of gastroduodenal artery.  

Step 4:  

Closed-suction transcutaneous drains are typically positioned at biliary and pancreatic anastomoses which are accompanied by supplementary drains positioned based on surgeon’s judgment. The conventional protocol is adhered to for the closure of abdomen.  

Step 5:  

Gupta etal., research suggested that employing negative pressure wound therapy might reduce the incidence of surgical site infections after pancreaticoduodenectomy.  

Laboratory tests 

Blood Chemistry Panel  

Serum Amylase and Lipase  

Imaging Studies  

Electrocardiogram  

Complications 

Bleeding  

Infection  

Pancreatic insufficiency  

Diabetes  

Wound complications  

Medications 

Pain Management:  

• Opioid analgesics:   Morphine, oxycodone, or hydromorphone helps to manage postoperative pain. The use of opioids is typically short-term to minimize the risk of addiction and other side effects.  
• Blood Thinners:  Blood thinners prevent blood clots development which can be problematic following surgery. The choice and duration of blood thinners will depend on the patient risk factors for clot formation.  

References

Pancreaticoduodenectomy – StatPearls – NCBI Bookshelf (nih.gov)  

Medication

References

Pancreaticoduodenectomy – StatPearls – NCBI Bookshelf (nih.gov)